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Full text of "United States Navy Medical News Letter Vol. 27, No. 11, 8 June 1956"

NavMed 369 




Editor - Captain L. B. Marshall, MC, USN (HET) 



Friday, 8 June 1956 No. 11 



TABLE OF CONTENTS 

Career Incentives 

Fate of Children with Bronchiectasis 

Acetylsuifisoxazole 

Myocardial Infarction in White and Negro Races 

Pulmonary Brucellosis 

Irradiation in the Treatment of Wilms' Tumor 

Renal Papillary Necrosis 

Leukoplakia of the Renal Pelvis and Ureter 

Problems Associated with Continuous Use of Sunglasses 
Training and Utilization of Hospital Corpsmen 



Revised Schedule of Postgraduate Course for Medical Officers 18 

From the Note Book * 

Board Certifications 20 

Recent Research Projects \ ' Zl 

Professional Medical and Dental Periodicals (BuMed Inst. 6820. 8) . . [ [ . ', 22 

Canadian Military Personnel, Care of (BuMed Inst. 6320. 20) 23 

Medical Intern Training Program {BuMed Inst. 1520. 9) 23 

"Slow Down and Live" Campaign (BuMed Notice 5101) 23 

Bureau Controlled Medical and Dental Items (BuMed Inst. 6700. 16) . . . . . 24 

Defective Medical and Dental Material (BuMed Inst. 6710. 30) 24 

DENTAL SECTION 

Protection from X-Ray Radiation. 25 Oral Surgery 27 

Dental Examination on SF 88 26 Board of Oral Surgery . . [ 28 

"Color Atlas of Oral Pathology 26 Alternates for Internship 28 

Base Command Program 27 Ensign 1995 Orientation 28 

Society of Oral Surgeons 27 Instructions and Notices 29 

MEDICAL RESERVE SECTION 

Correspondence Courses Available 29 

PREVENTIVE MEDICINE SECTION 



Industrial Noise Conference ..... 31 Insect Resistance to Insecticides. 34 
Training in Preventive Medicine. . 32 Swimming Pool Surface Film. , . 35 

Serologic Tests for Syphilis 33 Descaling Dishwashing Machines 37 

Outbreak of Infectious Hepatitis. . . 38 



2 



Medical News Letter, Vol. 27, No. 11 



Policy 

The U.S. Navy Medical News Letter is basically an official Medical 
Department publication inviting the attention of officers of the Medical 
Department of the Regular Navy and Naval Reserve to timely up-to-date 
items of official and professional interest relative to medicine, dentistry, 
and allied sciences. The amount of information used is only that necessary 
to inform adequately officers of the Medical Department of the existence 
and source of such information. The items used are neither intended to be 
nor are they susceptible to use by any officer as a substitute for any item 
or article in its original form. All readers of the News Letter are urged to 
obtain the original of those items of particular interest to the individual. 

SQa SjC 3{c Sji! 3(i 

Notic e 

Due to the shortage of medical officers, the Chief, Bureau of Medicine 
and Surgery, has recommended, and the Chief of Naval Personnel has con- 
curred, that Reserve Medical Officers now on active duty who desire to 
submit requests for extension of active duty at their present stations for a 
period of three months or more will be given favorable consideration. BuPers 
Instruction 19E6. IB applies. 

SjC sjc liffi (fs 3^ 

Career Incentives 

During the past year or so, a great deal of attention has been given to 
improving career incentives for the Armed Forces in general. This has been 
done to try to create a career military service which can compete with the 
attractive opportunities available in civilian pursuits. During the last session 
of Congress, a pay bill was passed which raised all military pay. The Con- 
tingency Option Act was also passed which gave military personnel the oppor- 
tunity to participate in a plan to increase the income of survivors of military 
personnel dying after retirement. At the present time, a Survivor Benefits 
Bill is under consideration by the Senate. This bill has already passed the 
House and provides more adequate and equitable benefits for survivors of 
active duty service personnel. Another bill that affects career attractiveness 
for the Armed Forces as a whole and is now under consideration by a Joint 
Committee in Congress is the Dependent Medical Care Bill. This bill would 
create uniform procedures for dependent medical care among all the Services, 
it would crystallize into law the present traditional medical care benefits and 
would improve the availability of dependent medical care to every serviceman. 



Medical News Letter, Vol. Z7, No. 11 



3 



The above actions have related to all segments of personnel in the 
Armed Forces. Certain groups have had problems peculiar to those groups, 
and certain legislation affecting only those groups has either been enacted or 
is pending. The bill relating to improving career incentives for Nurse Corps 
officers, which has just been introduced in Congress, is such a bill. This bill 
proposes to authorize 0. 2% of the strength of the Nurse Corps to be in the rank 
of Captain in the Navy, 5% in the rank of Commander, and unlimited promotion 
up to and including Lieutenant Commander based upon the running mate system. 
This bill also permits Nurse Corps officers to be members of Nurse Corps 
selection boards. A somewhat similar bill affecting the Medical Service Corps 
is expected to be proposed soon. This proposed bill would remove the limita- 
tion of 2% of the strength of the Corps in the rank of Captain in the Navy, 
and would also permit Medical Service Corps officers to be members of 
Medical Service Corps selection boards. 

Of great importance to the Medical and Dental Corps of the Armed 
Services is Public Law 497 of the 84th Congress. This bill was known as the 
Medical and Dental Officer Career Incenti ves Sill. One of its purposes was 
to equalize promotion for medical and dental officers by giving them credit 
for the time spent in medical or dental school and medical internship by bring- 
ing them up to a lineal position equal to their college graduate contemporaries 
in the line and other staff corps. Another purpose of the bill was to bring the 
pay of military medical and dental officers up to the range of pay of civilian 
physicians and dentists in other branches of the Federal service and to also 
lessen the disparity between military pay and that of the average income of 
civilian physicians and dentists. This bill provides four years of construc- 
tive service for the time spent in medical or dental school and one year of con- 
structive service for the year of medical internship for both promotion and pay 
purposes. It also authorizes total special pay for medical and dental officers 
as follows: $100 per month during the first two years of service as a medical 
or dental officer {exclusive of internship); $150 per month after two years and 
with less than six years of service as a medical or dental officer; $200 per 
month after six years and with less than 10 years of service as a medical or 
dental officer; $250 per month after 10 years of service as a medical or den- 
tal officer. This bill was signed by the President on 30 April 1956 and became 
law on 1 May 1956. AlNav 16-56 gives instructions concerning the procedures 
necessary to carry out the provisions of this law. 

Certain administrative actions not related to the legislative actions 
referred to above have also recently been taken to improve career attractive- 
ness for medical and dental officers. Chief among these are the following: 

1. Expansion of the Residency Training Program. 

2. Reduction of tours of sea duty for medical officers to 12 months 
except for those medical officers who are practicing their specialty at sea, 
as in the case of flight surgeons and submarine medical officers. This policy 
will become effective this summer when adequate replacements will be available 
from among the medical officers expected to report for active duty after 1 July 1956. 



4 



Medical News Letter, Vol. 27, No. 11 



3. The policy of accepting requests for voluntary retirement from all 
medical and dental officers with 20 or more years of active service. 

4. The policy of accepting resignations from regular medical and den- 
tal officers who have no obligated service for training and who have served 
two years or more on active duty. 

It has been and will continue to be the policy of the Surgeon General 
to constantly inquire into and recommend such action as is necessary to 
make careers in the Medical Department as attractive as possible. Just 
how successful this policy has been is evidenced by the fact that during the 
current fiscal year there have been more applicants for the Regular Navy in 
both the Medical and Dental Corps than during the past five years combined. 
These have far exceeded the attrition rate from all causes during this current 
fiscal year. (Bureau of Medicine and Surgery) 

****** 

Change of Address 

Please forward requests for change of address for the News Letter to: 
Commanding Officer, U.S. Naval Medical School, National Naval Medical 
Center, Bethesda 14, Md. , giving full name, rank, corps, and old and new 
addresses. 

****** 

Fate of Children with Bronchiectas is 

Although much has been written in recent years on the subject of 
bronchiectasis, few studies have dealt specifically with the disease in child- 
hood. Many authors observe how frequently the manifestations of this con- 
dition appear in early life, but in the main the prognosis and treatment of 
the disease in adults are considered. 

This article records the results of a follow-up study carried out during 
1950 on a group of children with bronchiectasis. These children were admitted 
to the Newcastle Regional Thoracic Surgery Centre between 1935 and 1948. 
All were under the age of 15 at the time of admission to the hospital when the 
diagnosis of bronchiectasis was established. As it was felt that at least 2 years 
were necessary to evaluate progress, only those cases in whom treatment 
was completed before December 1948 were included. There were 209 cases 
in the series and it was possible to follow-up 208 of them. The period of 
follow-up in these cases extends from 2 to 15 years with an average follow-up 
in the survivors of 6. 4 years. Although a much longer period of observation 
will be required before a proper estimate of progress can be made, many 



Medical News Letter, Vol, 27, No. 11 



5 



of the patients have been followed into adult life and at least some idea of 
their fate has been obtained. 

The 209 cases were composed of 119 girls and 90 boys; most observers 
seem to agree that the disease is slightly more common in the female sex. 

A study of this material gives some indication of the place of medical 
treatment in childhood bronchiectasis. It can be seen that cases of fairly 
localized cylindric bronchiectasis with mild symptoms do extremely well 
if treated conservatively. There was no mortality in these cases and, 
although most of them still have cough and sputum, they are able to lead a 
normal life without any restriction of activity. Cases in whom the disease 
is too extensive to warrant surgery must perforce be treated medically. 
Alexander and Strieder have estimated that about 50% of all bronchiectasis 
falls into this group, but with modern techniques the proportion is certainly 
less. Inevitably, the prognosis in a group of such cases will be bad and many 
will die of acute pulmonary infections or other complications. The occasional 
case, however, will show striking improvement and symptoms may diminish 
as the child grows up. In assessing the prognosis of such a case, the nature 
of the symptoms is often of greater importance than the anatomic extent of 
the bronchiectasis. Fetid sputum, copious expectoration, frequent feverish 
bouts and finger clubbing are unfavorable prognostic signs. Of the 17 med- 
ically treated cases with a fatal outcome, 9 had fetid sputum, 10 had very 
frequent feverish bouts, and 12 had clubbing of the fingers. The bronchiec- 
tasis was bilateral in 1 1 cases and in only 2 was it confined to one lobe. 

The bad results attending conservative treatment in the past have 
received a good deal of attention in the literature. Roles and Todd, Findlay 
and Graham, Perry and King, Riggins, Lisa and Rosenblatt, and Ford stress 
the high mortality in bronchiectasis treated medically; in the present group of 
61 cases on medical treatment, there were 17 deaths (mortality 28%), all of 
them within 5 years of being in the hospital. Thirteen of the 17 cases, however, 
were rejected as being too severe for surgical treatment and it is obvious that 
the mortality is mainly in this group. The majority of these deaths were 
known to have been caused by acute respiratory infections. Cookson and 
Mason have shown how these patients may undergo sudden and quite unexpec- 
ted changes for the worse. Nevertheless, with modern antibiotics, it is now 
possible to treat the infective complications which are the great danger of 
the disease and there is no doubt that with proper management much can be 
done for cases that, 10 or 15 years ago, would have had a very gloomy prog- 
nosis. 

Medical treatment plays a most important part in the preparation of 
patients for operation and, although this point has not been emphasized, all 
surgically treated cases in the present series underwent an intensive 
course of postural coughing, breathing training, and physical exercises 
before they were submitted to operation. One has only to observe the differ- 
ence in the general health of a child after 3 or 4 weeks of this treatment, to 



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Medical News Letter, Vol. 27, No. 11 



realize how effective it may be. At its best, however, medical treatment 
is essentially a palliative measure and, although much of the distress of the 
complaint inay be alleviated, the dangers of a fulminating lung infection, 
cerebral abscess, and other complications remain. 

If possible, surgical extirpation of the diseased area is the treatment 
of choice. The steady reduction in the operative mortality over the last 15 
years has made pneumonectomy and lobectomy reasonably safe procedures, 
and most workers are agreed that the risks of operation are least in child- 
hood. In the majority so treated, the results have been good and there seems 
every reason to expect continued good health in these cases. In many, a 
dramatic improvement has resulted from the cessation of cough, sputum, and 
febrile exacerbations following the operation, and even if all have not achieved 
complete freedom from symptoms, most of the patients have been benefited. 

Some authorities regard bronchiectasis as a disease which may spread 
insidiously throughout the lung. There was no evidence from a study of these 
cases to support this concept of bronchiectasis as a spreading process. The 
x-ray films taken at the follow-up examination did not show any clear evi- 
dence of spread either in cases treated conservatively or in those- following 
operation. This is in accord with the view of Churchill and Belsey, Perry 
and King, Diamond and VanLoon, and Lisa and Rosenblatt, who found that the 
extent of the disease was maximal at the time the diagnosis was made. Al- 
though fresh areas of bronchiectasis may appear if a suitably predisposing 
illness develops, this must be extremely rare, and in general, the pattern 
of the disease remains unchanged over long periods of time. Symptoms may 
increase in severity from time to time, but as this does not indicate spread 
of the disease, there is no urgency for surgical treatment on this account. 
The timing of the operation is an important matter and each child should be 
considered individually in this respect. 

It is shown that sinusitis is a frequent concomitant of the disease in 
childhood. In the majority of cases, this appears to be secondary to the 
bronchiectasis, but it undoubtedly plays a part in keeping the pulmonary 
infection alight; many febrile exacerbations of the disease start with an upper 
respiratory infection. Hence, in the preparation of these childr en for opera- 
tion, great attention is now paid to the treatment of sinus infection. Antral 
puncture and lavage, replacement with antibiotics, or regular displacements 
are usually helpful in minimizing nasal sepsis at the time of operation and in 
the postoperative period, and it is rarely advisable to resort to radical nasal 
surgery in children. Following the lung resection, further treatment is given 
if necessary and every attempt is made to clear up any residual paranasal 
infection before the child is discharged from the hospital. Persistent sinus- 
itis is probably an important cause of chest symptoms after operation. 

In the majority of these children, symptoms began in the early years 
of life. In nearly all cases, the disease begcin with an acute respiratory 
infection. The most common initial illness was pneumonia, but infectious 
diseases — particularly pertussis and measles — were also important. 



i 



Medical News Letter, Vol. 27, No. 11 



One hxindred and sixty-three cases were treated surgically. Pneumo- 
nectomy was performed in 48 cases, lobectomy or segmental resection in 112 
cases. The late results are described in these cases, many of whom have 
been followed into adult life. The effect of certain symptoms, notably asthma, 
on the prognosis of operated cases is discussed. 

Medical treatment was adopted in 46 cases and an additional 15 cases 
were considered, making a total of 61 cases treated conservatively. These 
cases are considered in three groups; (1) where the condition was too mild 
for surgery; (2} where the bronchiectasis was too severe for surgery; and 
(3) where surgical treatment was refused. The late results are described in 
each group. (Strang, C. , The Fate of Children with Bronchiectasis: Ann. Int. 
Med. , 44: 630-655, April 1956) 



Acetylsulfisoxa zole 

Acetyl-Gantrisin is the N' -acetyl derivative of Gantrisin (sulfisoxazole). 
The effectiveness of sulfisoxazole and its relative freedom from toxicity have 
made it a sulfonamide of choice. However, in suspension, its bitter taste 
and after -taste have been difficult to mask. Recently, an acetyl derivative 
has become available. The suspension forms of this compound have an 
excellent and very acceptable taste and it is, therefore, much easier to give 
to children. 

The purpose of this study was to evaluate the clinical effectiveness and 
toxicity of this new form of sulfisoxazole in suspension and to determine the 
influence of dosage and the time intervals between doses upon its concentra- 
tion in the blood and urine of children. 

The data on blood levels indicate that acetylsulfisoxazole is absorbed 
and excreted more slowly than sulfisoxazole. Peak levels are usually reached 
at 6 hours after a single dose compared to 4 hours with sulfisoxazole. The 
levels with the same dosage are relatively lower and more prolonged with 
acetylsulfisoxazole than those reported with similar doses of sulfisoxazole. 

Optimum minimum levels for clinical effectiveness are not known exactly. 
As with antibiotics, the relation between blood level and clinical effectiveness 
may be poor in many situations. Rhoads and co-workers found an average 
level of 9.4 mg. % sulfisoxazole to be effective in the treatment of meningo- 
coccal meningitis. He employed doses up to 3 to 4 gm. intravenously as the 
initial dosage in the children in his series. Iri such cases, it is probably wise 
to attain such levels initially by intravenous administration and, subsequently 
to use the larger oral dose (i. e. , 0. 3 gm per kilogram daily for maintenance). 

The therapeutic results indicate that the new suspension of acetylsulfi- 
soxazole is a useful drug in the treatment of common infections in infants and 
children, particularly where the older suspension of sulfisoxazole may be 
refused because of its taste. In this study, all but 11 of the 76 patients 



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Medical News Letter, Vol. 27, No. 11 



treated had a good to excellent response. Bigler and Thomas treated 71 chil- 
dren with otitis, tonsillitis, and pharyngitis, cervical adenitis, bronchitis, 
broncho -pneumonia, lobar pneumonia, and urinary infections with sulfisox- 
azole with an excellent response in all but 7. Price and Hansen, in a similar 
series of 82 children, but including 15 with diarrhea, noted an excellent res- 
ponse to sulfisoxazole in all but 9. 

It appears, therefore, in this series that the clinical results with acetyl- 
sulfisoxazole were comparable to those reported by others with sulfisoxazole. 

The particular advantage of acetylsulfisoxazole in suspension form is 
its almost universal acceptance by infants and children because of its excel- 
lent taste in the preparations. (Hagler, S. , et al. , Clinical and Laboratory 
Evaluation of Acetylsulfisoxazole {Acetyl -Gantrisin) in Children: J. Pediat. , 
48: 588-595, May 1956) 

iii yf/: iff ii: ijf :^ 

Myocardial Infarction in White and Negro Races 

None of the investigations into the etiology of coronary artery disease 
and its occurrence in females has considered the Negro race separately. 
In a previous communication, the authors reported the results of a study 
of 330 cases of proved myocardial infarctions; l62 were white and l68 were 
Negroid. While the Caucasian males outnumbered the females 3:1, there 
was no sex difference among the Negroes. 

The clinical records of 519 cases of proved myocardial infarction were 
reviewed. In each instance, the diagnosis was established by the clinical 
findings and substantiated by characteristic electrocardiographic changes 
or necropsy findings. 

The history of each case was thoroughly reviewed as to the presence 
of angina pectoris prior to infarction. Chest pain, that appeared two weeks 
or less before infarction, was considered to be premonitory and was not 
included in the analysis. Angina occurred with considerably greater frequency 
among members of the white race. More than twice as many white females 
{57%) as Negro females (26%) experienced this distressing symptom and one 
and one -half times as many white as Negro males. 

There were 233 white patients of whom 173 were males and 60 were 
females. This represents a sex ratio of 2.9:1 and is in general accord with 
the figure accepted in the literature. Of 286 Negro cases, however, 158 were 
males and 128 were females. This ratio of males to females is only 1.2:1 
and differs with high statistical significance from the sex ratio in whites. It 
is important to note that, in the many studies dealing with the sex incidence 
of coronary artery disease, the Negro race has never been specifically con- 
sidered. In the present series, the incidence of myocardial infarction in 
the Negro was approximately 52% of that in the Caucasian. 



Medical News Letter, Vol. 27, No. 11 



9 



A review of the age of all patients at the time of initial infarction re- 
vealed a further striking deviation from the classical picture described in 
coronary artery disease. The rarity of myocardial infarction in females, and 
especially in those of the younger age groups, has been regarded to be quite 
valuable in the differential diagnosis of chest pain. In a recent review of 
the literature, Thomas and Cohen found it generally accepted that myocardial 
infarction may occur in a few young men under the age of 40, but is extremely 
rare among young women of this age. They cited current reports confirming 
the following widely held views: (1) that there is a sharp increase in the in- 
cidence of coronary atherosclerosis between the ages of 30 and 40 in men and 
between the ages of 50 and 69 in women, and (2) that the incidence of marked 
coronary atherosclerosis in necropsy studies reaches a maximum between 
50 and 59 years of age in men, whereas in women, a plateau is reached after 
the seventh decade. Clinically, the initial appearance of myocardial infarc- 
tion is said to occur most often between the ages of 56 and 60; in a recent 
study, however, 39% of cases sustained the initial attack after the sixtieth 
year. In the present study, only four white females (6. 6%) suffered an infarc- 
tion prior to the fiftieth year of life, yet this occurred in 43 (33. 6%) of the 
Negro women. Before the age of 60, 81 Negro females (63%) had suffered 
a myocardial infarction as contrasted to only 13 (22%) of white females. While 
the observations in this series concerning white females, white males, and 
Negro males are in complete accord with those generally accepted, this is 
not true of the Negro females. Infarction actually occurred earlier in the 
Negro female than in any other category, even earlier than in the white male. 

The present investigation confirmed the observation that females having 
coronary artery disease tend to be more obese than do men afflicted with this 
condition. No significant racial difference was noted. Similarly, hyperten- 
sion was found to occur more frequently in the females of both races than 
in the males. This has been well established and no racial deviation was 
observed. An analysis of the frequency of a familial history of cardiovas- 
cular disease merely confirmed well -documented views. It was not possible 
to evaluate adequately the role of tobacco or alcohol in this study because of 
the large number of records not mentioning these agents. It became obvious, 
however, that all of the patients included in this series were from a similar 
economic level. No important differences in dietary habits were noted. Lab- 
oratory reports dealing with anemia were comparable in both races. 

The incidence of diabetes mellitus was similar in the males and in the 
females of both races. This metabolic disease occurred in 3. 5% of white 
males, 5. 1% of Negro males, 15% of white females, and 15. 6% of Negro 
females. 

Because of the startling absence of the usual sex incidence of myo- 
cardial infarction in Negroes, it was considered that ovarian dysfunction 
might be involved. However, no significant difference in productivity was 
observed between white and Negro females. It should be noted that 42% of 



10 



Medical News Letter, Vol. 27, No. 11 



the white cases and 41% of the Negroes could not be properly evaluated be- 
cause of inadequate records. Of possible significance was the observation 
that pelvic surgery during the childbearing period was performed on 20. 3% 
of the Negro females as contrasted with only 5% of the white cases, a ratio 
of 4:1. The importance of this finding remains to be determined. 

The mortality rate in the present study was greatest among the Negro 
females. This, again, is a startling deviation from the classical description 
of myocardial infarction in women. It would almost appear that coronary 
atherosclerosis is a different disease in the Negro female as compared with 
that described in the literature. The explanation of this variation presents 
a definite challenge. Further extensive study of the Negro female is essential 
and may well afford an insight into the pathogenesis of coronary artery disease. 
(Keil, P.G. , McVay, L. V. Jr., A Comparative Study of Myocardiallnfarction 
in the White and Negro Races: Circulation, XIII , 712-717, May 1956) 

Pulmonary Brucellosis 

Brucellosis is one of the most important of the new diseases discovered 
in recent times by bacteriological methods, and should be considered early 
in the diagnosis of an obscure illness. Unfortunately, there is no one reliable 
specific test generally available for the diagnosis. In the diagnosis of brucel- 
losis, the finding of Brucella by blood culture is diagnostic, but the test 
requires careful and rigid technique not available to the great group of prac- 
titioners most likely to observe the early cases. Then, too, the obtaining of 
a positive culture is largely a matter of accident in acute brucellosis and is 
rarely found in chronic brucellosis. One should emphasize that negativity of 
any one test does not necessarily indicate that a Brucellar infection is not 
present either in acute or chronic pulmonary brucellosis. 

The too great tendency of physicians to tell their patients they have 
recovered after several weeks treatment of the acute type, or a short term 
of therapy in the chronic phase, is wrong. One cannot be certain that such 
patients have recovered or might relapse into the chronic type of brucellosis. 
Their apparent immunity may or may not be due to a low-grade subclinical 
infection localized in the hilar and mediastinal lymph nodes, small nodularities 
withm the pulmonary parenchyma; or elsewhere in the body. The burden of 
proof as to whether a Brucellar infection is present should rest upon the attend- 
ing physician to properly interpret all available data —hi story, clinical symp- 
tomatology, and differential diagnostic procedures, in conjunction with relative 
evaluation of the intradermal, agglutination, and opsonocytophagic tests, and 
blood culture if available, combined with mature unbiased clinical knowledge 
•and judgment. 

Because blood cultures for Brucella are not readily available in a large 
proportion of the cases of chronic brucellosis, physicians must re-evaluate 



Medical News Letter, Vol. Z7, No. 11 11 



the specific importance of additional laboratory tests when blood cultural 
studies are not obtainable. The present-day tendency to rely on a few blood 
cultures, or blood cultures in conjunction with the agglutination test in chronic 
brucellosis, may lead to frequent diagnostic failures. It is true that the agglu- 
tination reaction is usually positive in cases with positive blood cultures, but 
this relationship is not necessarily true; in chronic brucellosis, especially 
the abortus type, the finding of a positive blood -agglutination reaction in a 
significant titer is the exception rather than the rule. Its persistent absence 
or presence in a low titer has been reported repeatedly in both acute and 
chronic cases with positive blood cultures; however, it is a valuable adjunct 
whenever a positive blood culture is not obtained. It is obvious that one can- 
not rely entirely on either the blood culture or the blood agglutination reaction 
singly, because one or both tests may be negative in both acute and chronic 
brucellosis. Especially is the latter statement true if the brucellar infection 
is well localized within the body of the patient. The agglutinins may be fleet- 
ing and bear no relationship to the activity of the disease. It is also an erron- 
eous concept that lessening of the blood -agglutination titer indicates a favorable 
prognosis. The intradermal brucellergin test should be deferred until after 
the agglutination and opsonocytophagic tests have been concluded; otherwise, 
agglutinins and opsonins may be stimulated and the value of the test of little 
importance. Many physicians use the skin test as the sole diagnostic pro- 
cedure. The significance of the test is comparable, generally speaking, to 
that of the intradermal tuberculin test, and if positive, indicates usually that 
the patient has been infected with Brucella at some previous time. A positive 
intradermal brucellergin reaction does not determine the present status of 
the brucellar infection. A positive intradermal reaction, whatever the degree — 
low or high when associated with the presence of specific opsonins, especially 
of low titers— indicates the presence of an infection with Brucella. The diag- 
nosis of active brucellosis depends upon the skill and judgment of the physicians 
and repeatedlaboratory and clinical observations over a period of months. In 
this way, a diagnosis may be made. One is not dealing with a disease similar 
to typhoid and typhus fevers, but more like tuberculosis; certainly, a patient 
with tuberculosis would not be discharged after three weeks' treatment with 
antibiotic therapy. It is well known that acute brucellosis frequently relapses 
and may persist as a low-grade infection for months or years or may remain 
localized for years, subsequently assuming an active status as a really severe 
disease process. The author's opinion is that in the cases with pulmonary in- 
volvement localization may occur in the hilar nodes and the small nodularities 
in the pulmonary parenchyma as observed in the x-ray films of the chests of 
cases in this series. (Greer, A. E, , Pulmonary Brucellosis: Dis. Chest, 
XXIX: 508-516, May 1956) 



# :ic sjc ^ 9$: :gc 



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Medical News Letter, Vol. 27, No. 11 
Irradiation in the Treatment of Wilms' Tumor 



Controversy still exists regarding the best method of treatment of malig- 
nant renal tumors in children. This article presents the results of treatment 
of 28 cases and suggests more extensive utilization of preoperative irradiation. 

While the true incidence of the disease is not known, it is thought to 
account for approximately 20% of malignant neoplasms in children and to rank 
in frequency with ocular neoplasms. Although the tumor is found most fre- 
quently in the first 4 years of life, it has been described in the fetus, the 
newborn, and in each decade up to and including the ninth. A large hard mass 
in the abdomen may be discovered by the parent or the physician during a rou- 
tine physical examination. Cases have been reported in which rupture of the 
tumor was the first indication of the disease. 

Rare cases of bilateral involvement have been described. The lesion 
has appeared simultaneously in identical twins on opposite aides, in three 
and possibly four children of one family, in a horseshoe kidney, in the isthmus 
of a horseshoe kidney, and in the remaining kidney of one patient 10 years after 
the removal of the opposite kidney for Wilms' tumor. 

The tumor remains confined by the renal capsule until late, and thus the 
capsule serves to prevent direct spread to adjacent organs. 

The re has been considerable opportunity to study the effect of irradia- 
tion on these tumors. Following irradiation, there is a rapid decrease in the 
size of the mass due to destruction of radiosensitive elements of the tumor. 
Histologically, there is necrosis, increase in fibrous stroma, and, occasion- 
ally, large fibroblasts having the appearance of "foreign-body type" giant 
cells. Perivascular fibrosis is an important feature. Changes in the adjacent 
kidney consist of degeneration of the tubules, increase in the fibrous stroma, 
and necrosis and hyalinization of the glomeruli. Some authors believe that 
calcification in the tumor is a good prognostic sign where hematuria, indicating 
invasion of the renal pelvis by the tumor, carries with it a grave outlook. 

It appears obvious that, although irradiation may hold the disease in 
abeyance for 2 or more years, nephrectomy is essential for a "cure. " 

Gross and Neuhauser advocate immediate nephrectomy complemented by 
postoperative irradiation directed to the renal fossa. This is based on their 
observation of 47% 2-year "cure" by that method as compared with their 
result of 32% "cure" for 2 years by operation alone. The authors are await- 
ing their report of 5-year studies on these cases. 

The authors have found metastatic lesions as late as 42 months following 
treatment with preoperative irradiation, and 6l months following irradiation 
alone. Furthermore, they deplore the application of radiation unless there 
is definite evidence of residual neoplasm. They do not feel justified in sub- 
jecting a patient to postoperative irradiation unless residual neoplasm is 
known to be present or is strongly suspected. 



Medical News Letter, Vol. 27, No. 11 



13 



Once the diagnosis of Wilms' tumor has been established with reason- 
able certainty, the authors recommend starting radiation therapy immediately. 
Their plan consists of treating the tumor with 200 kv. radiation, 50 cm. focal 
skin distance, 0.9 or 1.9 mm. Cu half-value layer, directed to adequate 
anterior and posterior portals. For large tumors, a lateral portal is added. 
Two hundred r in air are delivered to each of two portals daily. The total 
air dose has ranged between 3600 and 4800 r, to provide a tumor dose of be- 
tween 2000 and 3000 r. In the case of iincooperative patients, the authors 
have not hesitated to use a rectally administered general anesthetic. Eight 
to twelve weeks following the beginning of the irradiation, a nephrectomy is 
done. Following this, examination is recommended at intervals of not longer 
than 3 months including a roentgenogram of the chest for detection of metas- 
tasis to the lungs. In the event that pulmonary metastasis is discovered, 
irradiation is begun immediately. A tumor dose of approximately 1000 r is 
delivered to the involved area. (Kerr, H. D. , Flynn, R. E. , The Role of Irrad- 
iation in the Treatment of Wilms' Tumor in Children: Am. J. Roentgenol, , 
75: 971-975, May 1956) 

•{c 3^ 3jC 3^ !^ 

Renal Papillary Necrosis 

Renal papillary necrosis, also called necrosis of the renal papillae, 
necrotizing papillitis, and papillitis necroticans, is an uncommon condition 
usually found in diabetic patients, although it may occur in non- diabetics. 

In spite of the high mortality in these cases, the correct antemortem 
diagnosis is of more than academic interest because the disease has two im- 
portant characteristics that require a proper therapeutic regimen: (1) It is 
a suddenly developing and rapidly progressing necrotizing bacterial lesion 
that must be treated aggressively and without delay. (2) The 'selective 
necrosis involving the tips of the papillae impairs the urinary drainage of 
the associated nephrons, making definitely hazardous the use of sulfonamide 
drugs and related compounds with their known tendency to precipitate out in 
the renal tubules under conditions of urinary stasis or acid-base imbalance. 

The gross and microscipic features of this entity have been well docu- 
mented in the literature and have been shown to be remarkably constant, 
differing only slightly according to the stage of the disease at the time of 
pathologic examination. Also, the findings have been shown not to be influ- 
enced essentially by different etiologic organisms or by the presence or 
absence of diabetes. 

The radiographic findings in this entity are the result of destruction of 
the papillae and/or the associated inflammatory process. The roentgen diag- 
nosis is, therefore, dependent on the period or phase of the disease in which 
the examination is performed. A tabulation of the roentgen findings from 



14 



Medical News Letter, Vol. 27, No. 11 



the early to the late stages, as reported in the literature and observed, 
follows: 

1. Delay in or complete lack of function, most commonly unilateral, 
is probably the earliest roentgen finding. 

2. Mild to moderate dilatation of the collecting system may be seen. 
This maybe limited to a single calyx, a group of calyces, or the entire col- 
lecting system. This sequence of events may be reversed if there is obstruc- 
tion of the lower urinary tract. 

3. A mottled moth-eaten appearance of the fornices occurs. This 
results from necrosis and sloughing of the renal papillae. In this respect, 
the findings are similar to those seen in tuberculosis. 

4. Gross filling defects may be seen throughout the calyces and pelvis, 
representing necrotic slough and blood clots. 

5. An interesting phenomenon is the occurrence of "ring shadows. " 
These are radiolucent halos rimming dilated calyces. The halos probably 
represent defects left by a sequestrated papilla and occur in an advanced 
stage of the disease. The presence of numerous "xing shadows'" produces a 
striking radiographic picture. 

6. In advanced cases with peripheral necrosis and cavitation, the con- 
trast material is seen to extravasate into the renal cortex. Occasionally, a 
large portion of a pyramid may break off and float down to the renal pelvis 
where it will produce a filling defect simulating a tumor or nonopaque stone. 

The diseases to be considered in the radiographic differential diagnosis 
are renal tuberculosis, renal tumor, renal calculus associated with colic, and 
acute pyelonephritis without necrosis. (Evans, J. A. , Ross, W. D. , Renal 
Papillary Necrosis: Radiology, 66: 502-508, April 1956) 

****** 
' Leukoplakia of the Renal Pelvis and Ureter 

Leukoplakia of the renal pelvis and ureter is an infrequent lesion in the 
urinary tract. The etiology is as uncertain today as when first described in 
the bladder by Rokitansky in 1861, or when observed 20 years later in the 
renal pelvis by Ebstein. Leukoplakia is a disease of unknown etiology involv- 
ing mucous membranes as well as skin. In the urinary tract, it is character- 
ized by an epidermoid metaplasia of the mucosa in various stages with marked 
keratinization and desqiiamation. This condition, while rare, becomes of 
considerable clinical importance because of the iin satis factory treatment and 
the possibility of malignant degeneration. 

Leukoplakia occurs about equally among the sexes and is most common 
in the fourth decade with the third and fifth being next most common. It has 
been observed as early as 4 months and as late as 72 years. It is usually 
unilateral, occurring more frequently in the renal pelvis than in the ureter. 



Medical News Letter, Vol. 27, No. 11 



15 



Patch, in. an analysis of 152 cases of leukoplakia of the urinary tract, found 
the bladder involved 110 times, the renal pelvis 36, and the ureter only 6 
times. 

The presenting symptoms are those usually produced by, or associated 
with, the coexisting disease. Irritation or infection, usually present, may 
produce the presenting complaint. Flank pain, either dull or colicky, may 
be present. Hematuria, present in one of the three reported cases, occurred 
in 35% of the patients in Kutzmann's collection. The presence of flaky sub- 
stances in the urine or of a heavy sediment may be observed. 

The lack of any specific symptom renders the diagnosis difficult to 
make. Pyelographic changes alone are too inconsistent and variable to be of 
any definite diagnostic aid. The presence of cornified squamous epithelial 
cells in the urine should be considered pathognomonic . 

Leukoplakia is considered a premalignant lesion, and treatment should 
be directed with that in mind. Potts estimates that 8. 4% of squamous cell 
carcinoma follows leukoplakia. Kutzmann fotmd 8 malignant lesions in 67 
cases; however, only 5 of these were squamous cell carcinoma. The incidence 
of squamous cell carcinoma associated with leukoplakia is much too frequent 
to be coincidental, making the treatment of choice either nephrectomy or 
nephroureterectomy as the case may warrant. 

One should first ascertain the presence or absence of involvement of 
the other kidney by repeated cytologic studies. If the disease is bilateral, 
the treatment by necessity must be conservative. Treatment is directed 
toward the elimination of any existing infection and the promotion of drainage. 
Lavage and irrigations of the renal pelvis and the administration of large 
doses of vitamin A may be tried. (Politano, V. A. , Leukoplakia of the Renal 
Pelvis and Ureter: J. Urol., 75: 633-641, April 1956) 

Problems Associated with Continuous Use of Sungl asses 
and Tinted Lenses for Eliminati on of Glare 

As commonly used, the term "glare" has various meanings. Here, it 
will be used to signify any brightness within the field of vision of such char- 
acter as to cause an unpleasant sensation, a temporary blurring of vision, 
or eye fatigue. Infra-red probably adds nothing to the blurring of vision 
and, under normal conditions, little to eye fatigue. However, ultraviolet 
radiant energy definitely causes blurred vision as the result of fluorescence 
of the eyfe media. 

The elimination of glare from extensive areas of snow, water, sand, 
roadways, and city streets in bright sunlight by the use of tinted lenses is 
easy and satisfactory; there is no problem in making a selection by trial of 
a glass that will adequately serve the purpose. 



16 



Medical News Letter, Vol. 27, No. 11 



Through the continued use of dark lenses, it has been found that the 
eye becomes more or less accustomed to a lower illuminance or level of 
illumination so that glare may result when the eye is exposed to a certain 
higher level of illumination to about the same extent as if no glasses had ever 
been worn. On the other hand, if a person spends a major part of the time 
out of doors in sunlight, the eye becomes accustomed to the higher illumi- 
nances so that it may be possible to see comfortably without any glasses. 
However, most of us require protection during those times when we are out- 
side in bright sunlight because the greater part of our lives is spent indoors 
under a lower level of natural or artificial illumination. This "habit forming" 
characteristic of the eye can be controlled to a certain extent by guarding 
against the use of shaded lenses of any kind (except possibly in certain path- 
ological cases) while indoors or under conditions of similarly low illuminance. 
In most homes and offices the level of illumination is so low that the normal 
eye requires all the available light for comfortable seeing. The best lens^ 
with the usual light covering of dust, oil, et cetera, reduces the light flux 
density about 10%. The use of tinted lenses would reduce the visibility of 
objects even more. Hence, the practice of prescribing corrected tinted 
lenses for use in the home or office is probably erroneous in most cases 
because most inside working conditions now have illumination levels which 
are too low for best results. 

For use in sunlight, there is oftentimes a need for corrected lenses 
because eye fatigue may be caused by lack of proper refraction corrections 
as well as glare. This is especially the case on long automobile trips when 
the eyes are kept constantly fixed on the highway for hours at a time. For 
persons requiring corrected lenses, two alternatives are possible: the use 
of commercially available "clip on" protective sunglasses and prescription 
ground tinted lenses. If the refractive corrections are small for distant 
vision, corrected lenses made from tinted sunglass stock are preferable 
because the wearing of two sets of glasses over the eyes has a number of 
disadvantages. If, on the other hand, the refractive corrections are large, 
an excessive variation in shade over the area of the lens will result unless 
the lens is very thick. As most corrective glasses are converging, the 
resulting glass will be dark in the center and light around the edge — a con- 
dition just the opposite of that desired for most efficient reduction of glare. 

There are several possible solutions to this problem on non-uniform 
density. The use of a metalized coating on the finished corrective lens, that 
is made from clear glass, will produce a tinted sunglass of uniform density, 
which may be of any shade depending upon the amount of metal deposited upon 
the glass. The use of polaroid between clear glass plates will give a neutral 
glass having a luminous transmittance of about 35%. In this case, most of 
the absorption is within the polarizing layer which is not disturbed in grind- 
ing and polishing operations. Clear glass may be "flashed" to give any color 
or density by coating one side with colored glass. The glass may then be 



Medical News Letter, Vol. 27, No. 11 



17 



polished on both sides. If ground and polished slightly concave on the flashed 
side, a lens may be obtained that is of light shade or clear in the center with 
increasing density toward the edge. Any refractive corrections would then 
be ground on the clear surface of the glass. (Spectral-Transmis sive Proper- 
ties and Use of Eye -Protective Glasses: U.S. Department of Commerce, 
National Bureau of Standards Circular 471) (ProfDiv, BuMed) 

Sfs <{C 9^ jjc 

Training and Utilization of Hospital Corpsmen 

Maximum utilization of enlisted Hospital Corpsmen is mandatory if 
individual commands and the Medical Department as a whole are to success- 
fully accomplish their missions. To this end, training in basic Hospital Corps 
Schools has been reduced to a minimum and falls into three categories as 
follows : 

1. Enlistees with four years' obligated service are given the full course 
of instruction which was reduced from 20 weeks to 16 weeks on 1 February 
1956. This 16 weeks' course provides the same amount of instruction in 
nursing and other subjects directly related to patient care as did the 20 
weeks' course. This instruction is designed to equip Hospital Corpsmen 

to perform those operational duties common to all corpsmen during their 
first four years of duty. 

2. Hospital Corpsmen with only two years' obligated service are given 
12 weeks of basic fundamental training in Hospital Corps Schools. This 
course provides 150 hours' instruction in nursing as compared to 200 hours 
in the 16 weeks' course. This instruction is designed to equip corpsmen 

to perform operational duties common to all corpsmen during their first 
two years of active duty. 

3. Hospital Corpsmen with only two years' obligated service, whose 
civilian training and experience have qualified them as technicians in the 
Hospital Corps, are transferred direct from Recruit Training Centers 
with no Hospital Corps training to fill vacant billets in their specialty. 
Others in this category for whom no vacancies exist in their specialty are 
given 12 weeks' Hospital Corps training and are assigned as general duty 
Hospital Corpsmen imtil such time as vacancies occur. All are assigned 
the appropriate Navy Job Code number. 

After completion of the above basic training, Hospital Corpsmen are 
assigned duties in accordance with the needs of the service. As many as pos- 
sible are transferred to naval hospitals; however, it has been necessary to 
transfer some technicians with no basic Hospital Corps School training and 
some with only 12 weeks 'of such training direct to other shore stations, to 
the fleets and to the Fleet Marine Force without the benefit of hospital exper- 
ience prior to reporting to their first ship or station for duty. Responsible 



18 



Medical News Letter, Vol. 27, No. 11 



Medical Department personnel should give due consideration to the amount 
of basic training each has received and to special qualifications as related 
to billet requirements in the assignment and utilization of these Hospital 
Corpsmen. 

The above procedures were instituted in order to keep as many Hos- 
pital Corpsmen as possible in operational billets. It is equally important 
to maintain the quality of Hospital Corpsmen in operational billets at the high- 
est possible level. Therefore, all Hospital Corpsmen, and in particular, 
technicians who have received no training in basic Hospital Corps Schools and 
those who have received only 12 weeks' such training, should participate in an 
intensive well -organized inservice training program to qualify them to perform 
all the duties of their rate and for advancement within their rating. 

On-the-job training in work situations is an essential part of such a 
training program. Active participation and enthusiastic support on the part 
of every Medical Department officer and petty officer is necessary to insure 
an effective training program. (PersDiv, BuMed) 

3^ SQC ij|C 3^ 3{C 

Revision in Schedule of Postgraduate Course O ffered 
to Navy Medical Officers 

(Refer to Medical News Letter, Vol. 27, No. 10, p 20) 

Applications are desired from Regular Navy Medical officers and 
Reserve officers, who have recently reported to active duty, for attendance 
at a course of instruction in Preventive Medicine to be conducted at the 
Naval Medical School, National Naval Medical Center, Bethesda, Md., com- 
mencing 20 August 1956 and ending 21 December 1956, instead of commenc- 
ing 10 September 1956, as indicated in the Medical News Letter, Vol. 27, 
No. 10, p 20. 

Enrollment is limited to 12 officers of the Navy plus 12 officers of the 
U. S. Air Force. 

Requests from interested and eligible personnel should be submitted 
via official channels to the Chief, Bureau of Medicine and Surgery. Officers 
requesting the course must include in their requests an agreement to remain 
on active duty for a period of 18 weeks following its completion, or for 18 
weeks following the expiration of currently required active duty. 

Deadline for receipt of applications is now 15 July 1956. 

ALL OFFICERS PLEASE NOTE THE CHANGE IN CONVENING DATE, 
DEADLINE FOR RECEIPT OF APPLICATION, AND THE SERVICE AGREE- 
MENT, ALL OF WHICH ARE CHANGES FROM THE ORIGINAL COURSE AS 
PRINTED IN THE NEWS LETTER, VOL 27, NO. 10, P 20, 

Reliefs cannot be provided for those approved for attendance. Minimum 
security clearance classification of Secret is required. (ProfDiv, BuMed) 



Medical News Letter, Vol. 27, No. 11 



19 



From the Note Book 



1. Rear Admiral B. W. Hogan, MC USN, Surgeon General, U.S. Navy, 
received an honorary degree of Doctor of Science, at Marquette University, 
Milwaukee on June 3, 1956. (TIO, BuMed) 

Z. Rear Admiral B. E. Bradley, MC USN, Deputy and Assistant Chief, 
will represent the Bureau of Medicine and Surgery, and serve as a Military 
Delegate at the Annual House of Delegates' meetings of the American Med- 
ical Association, June 11 - 15, 1956. (TIO, BuMed} 

3. Rear Admiral R. A, Kern, MC USNR (Ret) was voted in office by the 
Board of Governors of the American College of Physicians, as President 
Elect, at the Annual Meeting. {TIO, BuMed) 

4. Captain F.J. Braceland, MC USNR (Inactive), Advisor and Consultant 

to the Surgeon General, U.S. Navy, took office as President of the American 
Psychiatric Association on May 4, 1956. (TIO, BuMed) 

5. Captain E. E. Hedbiom, MC USN, representing the Bureau of Medicine 
and Surgery, will present a series of lectures on Operation Deepfreeze I 

to the Staff at the U.S. Naval Hospitals, Philadelphia, Pa. , St. Albans, N. Y. , 
Newport, R.I. , and Chelsea, Mass., May 14 - 18, 1956. (TIO, BuMed) 

6. The third annual reimion of crew of the USS Enterprise (CVS -5) will be held 
in New York on September 1-3. Vice Admiral M. B. Gardner, Deputy Chief 
of Naval Operations, Navy Department, is honorary chairman, and Mr. M.S. 
Cochran, Findlay, Ohio, is chairman of the arrangements committee. (O. O. I. , 
Navy Dept. ) 

7. The Tenth Annual Reunion of officers who served at the USNH Brooklyn, 
N. Y. , during World War II, was held on 12 April 1956. This is believed to 
be the first such medical organization and the first meeting was held in 1946 
in honor of the late Captain G. E. Robertson, MC USN, who was the Command- 
ing Officer of the hospital during the War. (Captain J. A. deVeer, MC USNR 
(Ret) 

8. The U. S. Naval Dental Service Officer Trai ning Programs manual is 
currently being revised in the Dental Division, Bureau of Medicine and Surgery, 
for the fiscal year 1957. This manual will be distributed to all teaching facil- 
ities before the start of the next training year. (TIO, BuMed) 

9. A postgraduate seminar on diseases of the heart for more than 300 civ- 
ilian and Armed Forces medical officers will be conducted b)? the AFIP in 
CO- sponsorship with the American Heart Association, May 14 - 17. (AFIP) 



20 



Medical News Letter, Vol. 27, No. 11 



10. The use of spinal anesthesia in 8114 obstetrical cases suggests that the 
technique is safe, that tinder certain circumstances it has distinct advantages 
over other types of anesthesia and that it is applicable in approximately 70% of 
cases. (Am. J. Obst. & Gynec., May 1956; S. Surge, M. D. , C. E. Baldwin, Jr. , 
M.D. ) 

11. The May 1956 issue of the American Journal of Medicine presents a 
symposium on the Pathologic Physiology of Thyroid Diseases. The sympo- 
sium summarizes modern concepts of normal and morbid physiology of the 
thyroid gland with special consideration of the rational management of these 
diseases, 

12. An effective regimen for treatment of "low-salt syndrome, " utilizing 
Diamox, ammonium chloride, and mercurial diuretics is presented in Cir- 
culation, May 1956; A. L. Rubin, M.D. , W.S. Braveman, M.D. 

13. Most swallowed foreign objects will pass without difficulty if time is 
allowed. A few objects such as bobby pins and long straight pins may become 
stuck at the stomach outlet, at the ligament of Treitz, or lower in the small 
bowel. A magnet on a string or catheter is a simple and satisfactory method 
of removing magnetic foreign bodies from the stomach, duodenum, or jejunum. 
(J. Pediat. , May 1956; H.I, Laff, M.D., R. P. Allen, M.D.) 

14. Cancer diagnosis by bone marrow smears is discussed in Ann, Int. Med. , 
April 1956; C.H. Jaimet, M. D. , H. E. Amy, B.A. ) 

15. Four cases are reported from a series of 50 in which a new type of pros- 
thesis has been successfully fitted over blind unsightly eyes. {Arch. Ophth, , 
May 1956; R. B. Scott) 

16. The clinical courses of 37 diabetic patients with nodular intercapillary 
glomerulosclerosis and of 37 without this lesion are reviewed in the New 
England J. Med., May 10, 1956; F.H. Epstein, M. D. , V.J. Zupa, M.D.) 

He :^ 3}: ^fi 

Board Certifications 

American Board of An esthesiology 

CDR Thomas C. Deas MC USN 

American Board of Neurolo gical Surgery 

LCDR Sanf(jrd F. Rothenberg MC USNR (Active) 



Medical News Letterj Vol. 27, No. 11 



21 



American Board of Orthopedic Surgery 

CAPT Desales G. DuVigneaud MC USN 
CAPT Robert B. Johnson MC USN 

American Board of Pediatrics 

LT William S. Kiyasu MC USNR (Active) 

American Board of Radiology 

LT Theodore G. Balbus MC USNR (Active) 

American Board of Surgery 
" LCDR William C. Davis MC USN 

CAPT P. K. Perkins MC USN 

li: li: ■>!/: iff if/: 

Recent Research Projects 



Naval Medical Research Institute, NNMC, Bethesda, Md . 

1. A Rapid Reading and Handling System for Miniature Condenser Type 
Ionization Chambers. Memo Report 56-5. NM 000 018.07, 8 November 1955. 

2. Immunological Studies in Renal Homotransplantation. NM 007 071.21.04, 
1 December 1955. 

3. The Heats of Ionization and pK'A's of Some Buffers of Biochemical Interest 
at High Ionic Strength. NM 000 018.06.40, 22 December 1955. 

4. Surface Diffusion and Thermal Transpiration in Fine Tubes and Pores. 
NM 000 018. 06. 47, 12 January 1956. 

5. Histologic Changes in the Incisor Teeth of Rats Serially Sacrificed after 
Receiving 1500 r of 200 KV X-Ray Irradiation. NM 006 012. 04. 99, 19 January 
1956. 

6. Pharmacological Studies on Irradiated Animals. Part V. The Effects of 
Postirradiation Administration of Vitamin K on X-Ray Induced Mortality. 
NM 006 012. 05. 16, 19 January 1956. 

7. Further Studies with Cell -Free Extracts from Mouse Spleen on X-Ray 
Induced Mortality. NM 006 012.04,80, 25 January 1956. 

8. Investigation and Improvement of Systems for Simulating Instrument Con- 
ditions in Aviation Instrument Flight Training. {Instrument Flight Simulation) 
NM 001 056. 07. 04, 27 January 1956. 

9. A sensitive and Stable Direct Current Recorder Amplifier, Memo Report 
56-2. NM 000 018, 03, 7 February 1956.. 

10. Blood and Urinary 17-Hydr6xycorticosteroids in Patients with Severe Burns. 
NM 007 081. 22, 07, 8 February 1956. 

11. The Relationship Between Adrenal Weight and Population Status of Urban 
Norway Rats. NM 004 005. 08. 05, 23 February 1956. 



22 



Medical News Letter, Vol. 27, No. 11 



12. Demonstration of Corrosion Casts in Relationship to Gross Morphology 
by Embedding in Clear Plastic Models. NM 007 081. 14.02, 1 March 1956. 

13. The Inhibition of Steroidogenesis by Amphenone "B" In Vitro Studies 
Using the Perfused Calf Adrenal. NM 006 012.04,94, 1 March 1956. 

14. The Enzymatic Activity of Radiated Exteriorized Salivary Glands. NM 
006 012. 04.100, 11 March 1956. 

Naval Medical Research Unit No. 3, Cairo, Egypt 

1. Research Progress Summary Report. Period 1 January 1955 - 31 
December 1955. 

Naval Air Development Center, Johns ville, Pa. 

1. NADC-MA-5601. Determination of Cerebral Blood Flow Using Radioactive 
Krpyton. NM 001 100 301, 20 February 1966. 

2. NADC-MA-5602. A Study of Adaptation of Acceleration with Rats and 
Guinea Pigs as Test Animals. NM 001 100 306, 27 February 1956. 

3. NADC-MA-5603. A Method for the in Sjtu Study of Aortic Elasticity in 
the Dog. NM 001 100 315, 27 February 1956. 

Naval Medical Research Laboratory, Submarine Base, New London, C onn. 

1. An Evaluation of the Use of Baralyme in the Submarine Escape Appliance. 
NM 002 015. 08. 04, 9 February 1956. 

9|i: ^: ^ :{c 3|e 

BUMED INSTRUCTION 6820. 8 20 April 1956 

From: Chief, Bureau of Medicine and Surgery 

To: Non-BuMed Management Controlled Activities Having Medical /Dental 
Corps Personnel Assigned 

Subj: Professional medical and dental periodicals ; responsibility for 
notification of nonreceipt and changes of mailing address 

Ref: (a) BuMedlnst 6820. IB, Subj: Subscriptions to professional 
Periodicals 

(b) OpNav P213-105, Catalog of Naval Shore Activities 

(c) OpNav P213-107, Standard Navy Distribution List 

This instruction advises activities for whom periodicals have been purchased 
by the Bureau, in accordance with paragraph 4 of reference (a), that respon- 
sibility for notifying contractors of nonreceipt of periodicals and changes of 



Medical News Letter, Vol, Z7, No. 11 



23 



mailing address shall be assumed by the addressee. Paragraph 4b of reference 
(a) is canceled. 

BUMED INSTRUCTION 6320. 20 10 May 1956 

From: Chief, Bureau of Medicine and Surgery 

To: All Continental Stations Having Medical/Dental Personnel Regularly 
Assigned 

Subj: Medical and dental care of Canadian military personnel and their 
dependents 

Ref: (a) DOD Directive 6310. 5, same subject (Notal) 
(b) SecNavInst 6320. 5, same subject (Notal) 

This instruction is published for information and compliance with regard to 
medical and dental care provided Canadian military personnel serving in the 
United States, and their dependents, in Navy medical and dental treatment 
facilities, in accordance with references (a) and (b). 

****** 

BUMED INSTRUCTION. 1520. 9 11 May 1956 

From: Chief, Bureau of Medicine and Surgery 
To: All Naval Hospitals 

Subj: Medical intern training program 

Ref: (a) Essentials of an Approved Internship, Revised to December 4, 

1952, prepared by the Council on Medical Education and Hospitals 
of the American Medical Association 

This instruction sets forth pertinent data pertaining to medical intern training 
in naval hospitals to be effective after 1 July 1956. BuMed Instruction 1500. 3A 
is canceled, 30 June 1956. 

BUMED NOTICE 5101 15 May 1956 



From: Chief, Bureau of Medicine and Surgery 

To: Activities Under Management Control of BuMed 



24 



Medical News Letter, Vol. 27, No. 11 



Subj; "Slow Down and Live" Campaign 

End: (1) Sec Nav Notice 5101 of 40 Apr 1956 w/enclosure 
This notice transmits enclosure (1) for appropriate action. 

3!: 3|s 9|c :^ 9}: 

BUMED INSTRUCTION 6700.16 15 May 1956 

From: Chief, Bureau of Medicine and Surgery 

To: All Ships and Stations Having Medical/Dental Personnel Regularly 
Assigned 

Subjr Bureau controlled medical and dental items 

Ref: (a) BuMedlnst 6700. 14 (formerly 4442. 1 A), Subj: Levels of supply 
for medical and dental stores at consumer activities 

(b) BuMedlnst 6700. 9 (formerly 4220. 2A), Subj: Requisitioning and 
receipt of medical and dental material (Cognizance Symbol "L"); 
instructions concerning 

(c) BuMedlnst 6700. 13 (formerly 4441. 3), Subj: Authorized Initial Out- 
fitting Lists of Medical and Dental Material for Naval Vessels (Notal) 

(d) Art. 25-21(13) ManMed 

End: (1) Supplementary listing of Bureau controlled items applicable to 
activities under the management control of BuMed 
(2) Supplementary listing of Bureau controlled items applicable to 
activities Not under the management control of BuMed 

This instruction provides identification of Bureau controlled items and indicates 
the justification required on requisitions for such items. 

/ 

* * * ije 

BUMED INSTRUCTION 6710. 30 18 May 1956 

From: Chief, Bureau of Medicine and Surgery 
To: All Ships and Stations 

Subj: Defective medical and dental material; authority for disposition of 

Ref: (a) Medical and DentalMateriel Bulletin. EditionNo. 66 of 1 May 1956 
(b) Art 25-21 ManMed 

This instruction provides authority for disposal of defective material. 



Medical News Letter, Vol. 27, No. 11 



25 



DC1\TAI 




SEmOj\ 



Protecting Dental Personnel from X-Ray Radiation 

The National Commixiittee on Radiation Protection advises that 0. 3 r 
(roentgen) per week is the maximum permissible dose, either single or 
cumulative, for persons working with or in the vicinity of an x-ray machine. 
A full mouth series of 14 periapical films will expose the operator to 0. 01 r 
when standing 3 feet from the cone and out of the line of the useful beam. 
Under this condition, it is apparent that one operator can make approximately 
30 full mouth series (average, 3 seconds per film), or about 400 periapical 
roentgenograms per week and remain within the maximum permissible dose. 
The table below indicates safe distances and workload limits when an x-ray 
protective screen is not used and the operator is out of the line of the useful 
beam. The distances given are from the cone to the operator utilizing 10 
milliamperes. 



Distance 


Exposure 


Exposure 


Film s 


per Week 


(feet) 


(seconds) 


(MA seconds) 


(3 sec 


. average) 


2 


600 


6, 000 




200 


3 


1, 200 


12,000 




400 


4 


1, 600 


16,000 




525 


5 


2,000 


20, 000 




650 



Extreme care should be exercised by dental personnel to insure that maximum 
safety measures are employed at all times when working with or in the vicinity 
of the dental x-ray machine. These safety measures include: 

1. Not holding the film packet in the patient's mouth during exposure. 
' . 2. Not holding or "steadying" the cone with the hand during exposure. 

3. Standing behind the tube head and as far removed from the cone 
and the line of the useful beam as possible during exposure. 

4. Routine check for x-ray radiation through the wearing of film badges 
by personnel continuously exposed to secondary and/or stray radiation in the 
x-ray exposure room or adjacent spaces in compliance with NavMed P-1325 
(Radiological Safety Regulations). 



26 



Medical News Letter, Vol. 27, No. 11 



5. Rotation of personnel where the volume of x-. iiys approximates or 
exceeds the maximum permissible total weekly dose. 

6. Use of an x-ray protective screen when required. 

Dental activities with a photodosimetry requirement may requisition 
Holder, Radiac Detecting Element, Film Badge Type (FSN 6665-299-9825) 
and Film, Dental Radiographic, Radiac Detecting, 50s (FSN 6525 -299 -9824) 
from the Naval Supply Depot (Medical -Dental Stores Section), Mechanicsburg, 
Pa. Screen, X-Ray Protective (FSN 6525-612-8025) should be requisitioned 
when the workload is sufficient to justify its use. This item is 72 inches high, 
36 inches wide, and has a l6-inch center arc depth. 

National Bureau of Standards Handbook No. 60 of 1 December 1955 
(superseding HB No. 41) may be used for reference in determining structural 
shielding requirements for the protection of personnel in adjacent spaces 
when it is determined they are subject to exposure to excess secondary and/or 
stray radiation. 

****** 

Dental Examination on Standard F orm 88 

The Bur eau of Medicine and Surgery depends upon examining officers 
to evaluate and record their findings on the Standard Form 88. In reference 
to the dental examination. Article 6-58, Manual of the Medical Department, 
requires that "care shall be taken to indicate in each case whether or not 
the examinee meets the dental standards refated to the purpose of the examina- 
tion. Disqualifying defects shall be entered in detail. " When there is no state 
statement that the examinee "does or does not meet the dental standards, " 
or if other required information is missing, the final evaluation of the Stand- 
ard F orm 88 in the Bureau of Medicine and Surgery is delayed by the necessity 
of additional correspondence. This evaluation will be aided considerably if 
examining officers will enter in Block 44 whether or not the examinee meets 
dental standards. 

****** 

Color Atlas of Oral Pathology - 1956 
Distribution of Additional Co pies 

In the near future, additional copies of the Color Atlas of Oral Pathology 
will be distributed to the larger naval dental activities including those conduc- 
ting training programs. 

The Atlas has been received with great enthusiasm by the dental pro- 
fession and from Federal medical and dental services as evidenced by the 
warm praise contained in numerous letters received by the Bureau. 

****** 



Medical News Letter, Vol. 27, No. 11 



27 



Advanced Base Command Program 



Naval Reserve Dental officers are included in the allowances for the 
officer structure for three units in the Naval Reserve Advanced Base Com- 
mand Program as described in BuPers Instruction 4040. IC, 

These units are described as Lion Command Division, Cub Command 
Division, and Acorn Command Division. A Lion Division includes personnel 
for assignment to a large advanced base, Cub Division to a small advanced 
base, and Acorn Division to a Naval Air Station in an advanced base. 

The above units are also listed in the pay program. Members are 
required to conduct 48 drills and perform 2 weeks active duty for training 
each year. 

Information may be procured from District Commandants as to the avail- 
ability of billets in these divisions, 

ijf zlj: iff yj: ii: ijc 

Additional Member of the American Society 
of Oral Surgeons 

The Dental Corps News of 28 March 1956 contained a list of naval dental 
officers who are members of the American Society of Oral Surgeons. 

The name of Captain Joseph F. Link, DC USN, presently on duty at the 
Naval Dental Clinic, Norfolk, Va. , was erroneously omitted from this list. 

it: ^i: ^ iff ^ ^ 

Oral Surgery ; ■ >■ .< -f. 

Out of 538, 181 oral surgery procedures done in the Navy during 1955, 
a total of 27, l60 procedures or 5. 1% were done in naval hospitals. Of all 
oral surgery procedures, 44.8% were accomplished at recruit training centers. 
As might be expected, the oral surgery procedures done at naval hospitals are 
more complicated and time-consuming. For instance, in 1955, naval hospitals 
did 56% of all biopsies, 86. 3% of fractured mandible reductions, 84. 3% of 
fractured maxilla reductions, 75% of other fractured facial bone reductions, 
and 35.4% of tumor excisions. The great preponderance of all other cate- 
gories of oral surgery procedures was done at dental activities other than' 
naval hospitals. . ■ v 

sit sf: ^ !}: ![! ; ■ ' . . _ 

The printing of this publication has been approved by the Director of 
the Bureau of the Budget, 16 May 1955. 



28 



Medical News Letter, Vol. 27, No. 11 



Recently Appointed Diplomates of American 
Board of Oral Surgery 

Captain Gerald H. Bonnette, DC USN, U.S. Naval Hospital, Pensacola, 
Fla. , Captain Donald E. Cooksey, DC USN, U. S. Naval Dental School, 
National Naval Medical Center, Bethesda, Md. , and Commander Edward A. 
Gargiulo, DC USN, U.S. Naval Hospital, Beaufort, S.C., have recently 
notified the Dental Division, Bureau of Medicine and Surgery, of their cer- 
tification by the American Board of Oral Surgery. 

* * * 5jc jf: * 

Alternates for Dental Inter nship 

Ensign Donald C. Weikert, University of Maryland, and Ensign Jack 
G. Braswell, University of Louisville, have been selected into the Navy 
Dental Intern Program, replacing two ensigns originally selected for that 
program. 

^ ^ $ ;^ 

The Ensign 1995 Dental Orientation Program 

The Orientation Program was first established in fiscal year 1956 to 
. provide Ensigns 1995 (Dental) with training in naval dental and military pro- 
cedures. Through such training, the student ensign upon graduating from 
dental school may go directly into his professional duties without loss of 
time occasioned by the necessity of indoctrination. 

Last year this course proved to be very popular. A quota of one 
hiindred ensigns for 60 days' training was established during the year. In 
order to meet varying conditions at the dental colleges of the United States, 
training opportunities for more ensigns were made available by dividing 
these 60-day training periods into shorter periods. Thus, a quota of one 
ensign for 60 days' training could be divided into two periods for two ensigns 
for 30 days' training, or four periods of training for four ensigns for 15 days. 
Practically all of this quota was used during fiscal year 1956. 

There has been increasing interest in this training program as shown 
by the increased number of applications for training for the ensuing year. 
Most Districts have asked for increase in their quota. After a study was 
made of these additional requests, the Bureau of Naval Personnel, at the 
request of the Dental Division, granted an increase of quotas to approximately 
133, the increases being alloted mainly to those Districts in which there was 
a greater demand. 



9|c 4: 9^ 



Medical News Letter, Vol. 27, No. 11 



29 



BuMed Instructions and Notices 

BuMed Instruction 6820.8 o£ April 20, 1956 — Professional, medical, 
and dental periodicals; responsibility for notification of nonreceipt and 
change of mailing address. 

Purpose: To advise dental activities for whom periodicals have been 
purchased by the Bureau that it is their responsibility to notify contractors 
of nonreceipt of periodicals and changes of mailing address. 

BuMed Notice 6750 of April 17 1956 — NavMed 1301 Statement and Inven- 
tory of Precious and Special Dental Metals; preparation and submission of. 

Purpose : To restrict the requirement for the preparation and submis- 
sion of NavMed-1301 to those dental activities authorized to provide dental 
prosthetic care. 

BuMed Notice 1500 of April 17 1956 — This notice contains a Bureau 
policy statement that newly appointed dental officers may not request author- 
ization orders or temporary additional duty for the purpose of taking state 
board licensure examinations. Further, this notice suggests that dental 
officers desiring to take state board examinations should request annual 
leave for this purpose. 

s{; ^ ;J: :{e sic 



MEDICAL RESERVE SECTIOI\ 



Correspondence Courses Available 



Two excellent correspondence courses entitled. Manual of the Medical 
Department, Part I, NavPers 10708 and Manual of the Medical Department, 
Part II, NavPers 10709, are available to eligible Regular and Reserve officer 
and enlisted personnel of the Medical Department. 

Manual of the Medical Department, Part I 

This course is designed to allow Medical Department personnel to 
familiarize themselves with the fTonctions of administration, organization, 
and management of facilities under the cognizance of the Bureau of Medicine 
and Surgery. 

In matters of administration, the Medical Department is guided by Navy 
Regulations, current Bureau of Medicine and Surgery directives, and the 




30 



Medical News Letter, Vol. 27, No. 11 



Manual of the Medical Department, therefore, certain chapters of the Manual 
of the Medical Department have been included as the principal text for the 
course. The material embraces authoritative methods and procedures and 
discussions of approved essential organizational structure of the Medical 
Department components from the Bureau of Medicine and Surgery, the 
various field agencies in all areas of activities, through the regional and 
Naval District medical staff to the Medical Department organization in ships 
and on shore stations. 

Completion of this course will enable the enrollee to acquire essential 
knowledge of the significant functions of the Medical Department in its relation 
to the Naval Establishment ashore and afloat in all of its far-flung activities 
and increase his or her over -all efficiency. 

Consisting of ten objective question type assignments, the course is 
evaluated at 24 Naval Reserve promotion and non-disability retirement 
points. Completion letters are prepared upon satisfactory completion of 
assigmiients as follows: 1 through 5-15 points; 6 through 10-12 points. 

Manual of the Medical Department, Par t II 

This course is designed to acquaint and familiarize Medical Department 
personnel with the procedures that must be followed in performing professional 
and administrative functions. 

The course is based on Army Regulations 40-115 which is the regulation 
establishing physical and mental standards for induction and enlistment to be 
used by the Armed Services, and on chapters 15. 23, 24, 25. and Appendix A 
of the Manual of the Medical Department, 1952 edition; physical standards, 
methods of procedure in conducting physical examinations, and physical pro- 
filing required for original appointment and promotion to commissioned rank, 
appointment to the Naval Academy, enlistments and inductions in the Navy and 
Marine Corps. Included in this material is the necessary criteria concerning 
the use of forms and reports for the purpose of recording the physical exam- 
ination findings. Pertinent information relating to reports, forms, and records 
requirements, and fiscal and property management procedures is covered by 
chapters 23, 24, and 25 of the Manual of the Medical Department. Sample 
copies of certain selected DD, NavCompt, NavExos, PHS, NavMed, and 
Standard Forms are included for information and guidance. Appendix A, 
Treaties and Conventions, delineates the responsibilities of the personnel of 
the Medical Department in relation to international treaties and, conventions 
adopted by the United States Government, including the handling of sick or 
wounded personnel and war prisoners on land and sea. 

Consisting of eight objective question type assignments, the course is 
evaluated at 18 Naval Reserve promotion and non-disability retirement points. 
Completion letters are prepared upon satisfactory completion of assignments 
as follows: 1 through 5-12 points; 6 through 8-6 points. 



Medical News Letter, Vol. 27, No. 11 



3 



Applications for the foregoing courses should be submitted on form 
NavPers 992 (Rev 10-54) and forwarded via appropriate official channels to 
the Comimanding Officer, U.S. Naval Medical School, Correspondence 
Training Division, National Naval Medical Center, Bethesda 14, Md. 



PREVENTIVE MEDICINE SECTION 



Third Industrial Noise Conference 

The Third Industrial Noise Conference was held November 15, 1955 
in Buffalo, N. Y. , The conference was sponsored by the Associated Industrie 
of New York, Inc. The papers presented were classified into five groups 
dealing with various aspects of industrial noise: 

1. Principles of hearing measurement 

2. Principles of ear protection 

3. Practical problems in industrial ear protection 

4. Principles of noise control 

5. Practical applications of noise control 

The various disciplines necessary to conduct a successful hearing con. 
servation program were mentioned, i. e. , the physician, the industrial 
hygienist, the nurse, the acoustical engineer, the audiologist, the plant engi 
neer, and the worker. 

It was the consensus that the best ear protectors are usually composed 
of pliable or semipliable plastic and insert into the ear canal. Most of the 
acceptable protectors on the market provide 10 to 15 decibels attenuation 
below 1000 cycles per second and 15-40 decibels above 1000 cycles per 
second in regular field use. With adequate knowledge of the noise exposure, 
it should be possible to estimate the degree of protection to be expected. 
This is especially applicable in those industries in which the control of noise 
by engineering methods is impractical. 

Whatever the approach to an ear protection program, it seems certain 
that considerable thought must be given to program organization. Equally 
important is the exercise of close employee supervision to insure desired 
results . 



3Z 



Medical News Letter, Vol. 27, No. 11 



I 



The control of any hazard at the source or by engineering means is 
usually preferable to the provision of personal protection. In approaching 
the problem of noise control, an understanding of the basic principles in- 
volved is essential. These principles are: 

1. Substitution of less noisy operations 

2. Eliminating noise at its source 

3. Isolation of the noise source or of the worker 

4. Increasing distance between the noise source and the exposed 
workers 

5. Providing sound absorption 

6. Personal protective equipment 

There are no set procedures in establishing a hearing conservation 
program in industry. However, the potential importance of this problem 
suggests the need for a positive program wherever potential noise hazards 
exist. A possible approach might be as follows: 

1. Make one person responsible for the program on either a full-time 
or a part-time basis. 

2. Outline a hearing conservation program 

3. Evaluate noise exposures 

4. Establish noise control areas 

5. Establish a noise control committee 

6. Establish an audiometric testing program 

(Walworth, Herbert T. , Summary of Report on the Third Industrial Noise 
Conference: Am. Indust. Hyg. Assn. Quarterly!., 17: 58, March 1956) 

Note: Naval industrial activities should find the principles emphasized in 
the foregoing abstract helpful in resolving noise problems. 

Postgraduate Training in Preventive Medicine 
Leading to a Degree 

There is a critical need for medical officers trained in the basic dis- 
ciplines of public health: epidemiology, biostatistic s, microbiology, sanitary 
engineering, and public health administration. 

Medical officers of the Regular Navy and Reserve officers who contem- 
plate transfer to the Regular Navy or who have completed their obligated 
service and request extension of active duty for two years after completion 
of training, and who desire to specialize in preventive medicine, are invited 
to make immediate application for one academic year of postgraduate training 
beginning in August, September, or early October 1956. The choice of school 
can be made for this training which may be taken at any one of the accredited 
schools of public health in the United States offering a course leading to the 



Medical News Letter, Vol. 27, No. 11 



33 



degree of Master of Public Health or an equivalent certificate. Applications 
should be forwarded as soon as possible to the Chief of the Bureau of Medicine 
and Surgery, via the commanding officer, with a reference to this article, and 
should be accompanied by an appropriate obligated service agreement in accor- 
dance with BuMed Instruction 1520. 7 of 4 August 1954. 

Several schools of public health also afford opportunity for specialized 
study in industrial health leading to the degree of Master of Industrial Health. 

Among the interesting assignments available to young medical officers 
who successfully complete the course are: preventive medicine units ashore 
both in the continental United States and in overseas areas; medical research 
units; preventive medicine duties at naval training stations; the Bureau of 
Medicine and Surgery; and various naval schools as instructors in such sub- 
jects as epidemiology, environmental health, preventive medicine, and related 
laboratory sciences. For those who major in industrial health, there are oppor- 
tunities for assignment as industrial medical officers in the various naval 
industrial activities. The basic courses are also of value to any medical officer 
interested in clinical research, aviation medicine, submarine medicine, preven- 
tive psychiatry, or various other facets of Navy medicine. 

The broad knowledge and experience to be gained in a successful career 
in preventive medicine, whether it be in public health or in occupational health 
in the Navy, provide outstanding preparation for the responsibilities to be 
assumed with advancement in rank through the senior grades. Such knowledge 
and experience also provide the background necessary for appointment to many 
occupational health positions, public health positions, and teaching posts in 
civilian medicine when the Navy career is completed. Successful completion 
of this training meets part of the academic requirement for the American Board 
of Preventive Medicine and for certification by examination in public health, 
aviation medicine, or occupational medicine. 

At least four or five more applicants are urgently needed this year to 
fill existing vacancies in the preventive medicine service of the Navy, Can- 
didates desiring more information on postgraduate training in preventive 
medicine are invited to direct their questionis to the Bureau of Medicine and 
Surgery. 

sj: 4: 4: ^ 

Ser ologic Tests for Syphilis 

In a recent issue of the U.S. Navy Medical News Letter, (Vol. 27, 
No. 8, ppv. 35-36, 23 March 1956), an article on the Treponema pallidum 
Immobilization Test for Syphilis (TPI) appeared indicating the value of this 
test in the differential diagnosis between syphilis and a biologic false -positive 
result in standard serological tests. In the February 1956 issue of the American 
Journal of Public Health(Vol. 46, No. 2, pp. 190 - 194), Harold J. Magnuson, 
M. D., and Joseph Portnoy, Ph.D., report briefly on the Treponema 



34 



Medical News Letter, Vol, 27, No. 11 



pallidum Complement-Fixation Test (TPCF). From th^ data presented, this 
test appears to be somewhat more reactive in primary and secondary syphilis 
whereas the TPI test gave a higher percentage of positives in central nervous * 
system syphilis. The TPCF and TPI tests had better than 90% correlation in 
biologic false -positives. 

The authors point out the great value of the TPI test and the limitations 
of this test m general usage because of the technical difficulties associated 
with Its use. Commercial preparation of the TPCF test antigen is being under- 
taken by two firms. If further evaluation of this test confirms its apparent 
value for the recognition of syphilis, it is anticipated that any well-run sero- 
logic laboratory will be able to perform it. 

.v, TT^^^''"'^''^^^''''''^ comparison of a number of serologic tests, including 
the TPCF and TPI tests, is being undertaken in an effort to further define 
the relative value of the different tests in the hands of different laboratories 
r/!-^''!'^'^^'^^ laboratory at the Naval Medical School, National Na'val 

Medical Center, Bethesda 14, Md. , will be one of the participating laboratories 
m these studies Within a year or so, these studies should provide much better 

metr/.TYVn f ^ '"^ '^^^ — standardized 

methods to be followed in the serologic diagnosis of syphilis. 

****** 
Resistance of Insects to Insecticides 

The dramatic reduction in the incidence of arthropodborne diseases 
which has been brought about by the widespread use of DDT and other chlor- 
inated hydrocarbon insecticides, is well known. For several years it was 
thought that at last man had weapons with which the vectors of malaria and 
other formerly disastrous diseases could be eradicated. 

These idealistic expectations were short-lived, however, and the 
development of resistance to this group of insecticides by medically impor- 
tant insects has become widespread. An appreciation of the scope of this 
problem can be derived from the fact that insecticide resistance has now been 

mrmM^^t'" . bugs, body lice, cockroaches, fleas, sand- 

flies (Phlebotomus). houseflies, and at least 17 species of mosquitoes 

While the detection of insecticide resistance is important in all insect- 
control operations, it is imperative that entomologists working with military 
forces in the field anticipate the development of resistant strains of medically- 
SucT orf "'r*' ""^ prepared to detect insect resistance in its incipiencl. 
Such preparedness is urgent in order to prevent the occurrence of casualties 
and to forestall any unnecessary burden on the supply system of the military 
forces involved. As with other supplies, insecticides for military campaigns 
must be procured well in advance of the operation, and, if the insecticides 
prove noneffective, serious epidemics may result before satisfactory replace- 
ment materials can be developed and delivered to the theater of operations. 



Medical News Letter, Vol. 27, No. 11 



35 



The knowledge that many insects are resistant to insecticides is so 
well disseminated that many times, unfortunately, resistance is used as an 
excuse for not doing propfer control work. Initially, reports of resistance 
should be viewed with some skepticism; other possible reasons for lack of 
adequate control such as improper application of materials, improper mix- 
ing, faulty labeling of containers, decomposition of insecticide, et cetera, 
should first be ruled out before the conclusion is reached that resistance has 
been encountered. The opinions of experienced operators should be respected, 
however, since they are the first to notice when standard insecticides begin 
to show less than the usual degree of control and to find that more frequent 
and heavier applications are necessary. 

Because of the problems outlined above, it has appeared desirable to 
prepare instructions for comparatively simple standard tests that can be used 
to determine whether the common arthropods of military importance have 
developed resistance to the insecticides used by the Armed Forces. It is 
believed that such tests are completely necessary if the utmost in economy 
and safety of the military pest-control program is to be accomplished. 

Accordingly, a proposed manual of standard tests has been jointly 
prepared by the entomological personnel of the Army Environmental Health 
Laboratory and the Naval Medical School. Copies of the manual manuscript 
have been submitted to the Preventive Medicine Units and to other agencies 
employing specialists in the field of insect control with the request that 
appropriate comments and/or sugges.tions and significant test results be 
submitted to the Bureau of Medicine and Surgery. The Surgeons General of 
the Army and the Air Force are following a similar plan. The manual's 
publication and distribution early in 1957 are in prospect. 

To expedite the determination of a suitable set of standard test methods 
and to insure that all information of possible value to the study of insecticide 
resistance is made available, field activities are invited to take pertinent 
problems to their appropriate District or Senior Command level technical 
personnel. 

4^ lii )i: ^ 

Surface Film on Swimming Pools 

(The following is an abstract of an article in the March 1956 issue of the 
Canadian Journal of Public Health , implications of which are far-reaching 
and appear to open the door to new facets of swimming-pool sanitation not 
seriously considered in the past. ) 

Those who have studied the problem of swimming-pool sanitation are 
well aware of the many ways in which the water may become polluted. 
There are certain types of pollution which are not controlled by routine 



36 



Medical News Letter, Vol. 27, No. 11 



methods. Samples of water, taken in the conventional manner one foot 
or more below the sruface, may be accepted as representative of the 
main body of the water, but they, fail to disclose the conditions existing 
at the air-water interface. It is on the surface of the water that mucus 
and associated bacteria from the respiratory tract collect, and it is here 
also that sebaceous secretions, sun-tan oils, and water -insoluble consti- 
tuents of other cosmetic preparations tend to accumulate. The surface 
film thus produced must inevitably enter the mouth and nasal passages 
of the bather; in this manner, infective agents may be transmitted from 
one person to another even though there is an effective concentration of 
chlorine in the water below. 

This concept of pollution from surface films is now being studied 
experimentally in the laboratory of the author in order to assess its impor. 
tance as a practical problem. The first step was to find some means of 
collecting samples of surface film in a quantitative manner. This was 
accomplished by making use of the properties of calcium alginate. A des- 
cription of the results so far obtained are presented 

The results suggest that before a swimming-pool can be pronoimced 
as satisfactory, the surface water as well as the main body of the water 
should be examined bacteriologically. Six samples of surface water taken 
at different sites should be collected when the pool is in use, preferably 
during the period of heaviest load for the day. At present, collection of 
surface film on alginate gauze is the only method capable of giving quan- 
titative results. 

Most swimming-pools as now constructed and operated depend upon 
overflow gutters for the removal of surface pollution. The importance of 
these gutters is emphasized by the present studies. According to the 
recommendations of the American Public Health Association on which 
most official regulations in North America are based, drainage from over- 
flow gutters maybe discharged to sewers or to suction of recirculation 
pumps. The former method is here advocated because it continuously re- 
moves that portion of the water which carries most of the bacteria likely 
to cause human disease. Gutters should extend around the entire pool, 
not at the deep end only as is often the case. 

Surface film could be swept into the gutters at regular intervals by 
mechanical means. This could be done, for example, by a light but rigid 
plastic tube, closed at both ends, and a few inches shorter than the width 
of the pool. This tube, floating on the surface of the water, would be slowly 
towed from one end of the pool to the other by 2 attendants, one on each 
side. This procedure could be repeated once an hour, the pool being 
cleared of swimmers for a few minutes to allow this to be carried out. 

It is difficult to obtain reliable information about the amount of illness 
attributable to swimming pools. The general opinion is that there is more 



Medical News Letter, Vol. 27, No. 11 



37 



upper respiratory infection in swimmers than in nonswimmers; but against 
this must be set the health-promoting effect of a well managed pool. 

The presence of viruses in swimming-pool water has not yet been demon- 
strated directly, though inclusion conjunctivitis (if this disease is accepted 
as a viral infection) is certainly transmitted in this manner. Evidence is 
rapidly accumulating that swimming pools play an important role in the 
spread of pharyngeal conjunctival fever. The alginate method of collecting 
surface film may prove of value to virologists planning further research 
on this subject. (Amies, C.R., M.S., MRCP, (Lond. ), Department of 
Bacteriology and Provincial Laboratory of Public Health, University of 
Alberta, Edmonton, Canada; Surface Film on Swimming Pools: Canad. J. 
Pub. Health, 47: 93-102, March 1956) 

Descaling Dishwashing Machines 

The accumulation of scale deposits in dishwashing machines is of public 
health significance for at least two reasons: Excessive scale deposit on the 
inside of piping and pumps clogs them and interferes with the efficient perfor- 
mance of the machines by reducing the volume of water that comes in contact 
with the utensil in the washing and sanitizing process. Furthermore, scale 
deposits may provide a haven for dangerous bacteria. 

The following method of descaling dishwashing machines has been found 
to be effective yet safe enough to be, used by personnel trained in maintenance 
procedures : 

1. Half fill the tanks to overflow level with hot clean water. 

2. Add the required amounts of acid and wetting agent to prepare 
the cleaning solution (7 fluid ounces Orthophosphoric Acid 85% 
plus 1/2 fluid ounces wetting agent for each gallon capacity of : 
the tank when filled to overflow level). 

3. Complete filling tanks to overflow level. 

4. With scrap trays, spray arms, and curtains in place, operate 
the machine at the highest possible temperature for 30 minutes. 

5. Remove the cleaning solution completely by draining the tank 
and rinsing it thoroughly by refilling with fresh hot water and 
then operating the machine — again at the highest possible tem- 
perature — for 5 minutes. The rinsing procedure should be 
repeated several times. 

The supplies required for descaling are available through Navy supply 
channels as follows: 

1. Orthophosphoric Acid 85%, Technical, 7-lb. bottle. Stock No. 
G6810-264-6722. 



38 



Medical News Letter, Vol. 27, No. 11 2. 



2. Wetting Agent, 1-qt bottle, Stock No. G6850-282 -9702 
Wetting Agent, 1 -gallon can. Stock No. G6850-282-9699. 
Wetting Agent, 5 -gallon drum, Stock No. G6850-Z82-9701. 
When the capacity of dishwashing machine tanks is unknown, inside 
dimensions (in inches) of each tank may be applied to the following formula 
to calculate capacity in gallons: 

Length X width x depth (to water line) _ capacity in gallons 
231 

The method described should be repeated at such intervals as may be 
required to assure freedom from interference with efficient operation of the 
dishwashing machine. 

Outbreak of Infectious Hepatitis 

The following discussion of an outbreak of infectious hepatitis at a 
Marine Air Base in Korea was contained in the monthly report from Pre- 
ventive Medicine Unit No. 8 for February 1956. The full report contained 
a detailed epidemiologic study of the epidemic and effects of gamma globulin. 
The summary is published as an example of the service which preventive 
medicine units can perform for operational units in the field and as an illus- 
tration of the educational value of the results of such investigations when 
carried out by competent investigators. 

An outbreak of 25 cases of infectious hepatitis with jaundice occurred 
at a Marine Air Base in Korea during the 93-day period from 15 July to 16 
October 1955. Two additional cases of hepatitis were suspected — both 
anicteric — during this period. No cases had occurred at this base during 
the 4 months prior to this outbreak and no cases occurred for at least 3 
months following 16 October. Epidemiological data suggested that all but 
one of the first 17 cases were probably infected at about the same time, per- 
haps from a common source, but it could not be ascertained whether the 
source was food or contact with a subclinical or convalescent carrier. The 
later group of patients in the outbreak were more scattered in both location 
and time and probably were not infected by a common source. 

Investigation of the outbreak at the beginning of September revealed 
that most of the patients known at that time, including three food handlers, 
had been on duty for several days after the onset of symptoms. The personnel 
of this base represented a militarily critical group located in an endemic area 
of hepatitis where wholly satisfactory control of the environment, control of 
potential carriers, and proper isolation of cases were considered unlikely. 
Because of these facts, personnel of components with the largest incidence 
of cases were inoculated with gamma globulin on 7 and 8 September. Individ- 
uals weighing 180 pounds or less received 1. 5 cc. and those weighing more 



Medical News Letter, Vol. 27, No. 11 



39 



than 180 pounds received 2.0 cc. Personnel coming into these particular 
components during September and October were also inoculated. 

Six cases occurred after the initial mass inoculation, four among 1627 
uninoculated personnel who were on station at the time of the initial inocula- 
tion or who came aboard during the ensuing 4-month study period, and two 
among the 1710 inoculated base personnel. Of the two cases in inoculated 
personnel, one occurred 4 days after inoculation, the other 12 days after 
inoculation. The latter was one of the suspected, but unproven, anicteric 
cases. The number of cases occurring after the initial mass inoculation 
was too small to evaluate the efficacy of the mass procedure by comparison 
with the uninoculated group, but, considering the previous incidence rate 
among the inoculated components, one might have expected a larger number 
of cases had the gamma globulin not been used. The fact that no cases of 
infectious hepatitis have occured at this base among either the inoculated or 
the uninoculated personnel for the 3 months immediately past in spite of the 
constant arrival of newcomers to the base and the discontinuance of gamma 
globulin inoculations at the end of October, was somewhat unexpected and is 
unexplained. 

It is known that immune gamma globulin in certain dosage gives passive 
protection against infectious hepatitis as late as- 6 days before onset of the 
disease and lasting 6 to 8 weeks. It is not clear whether or not modification 
of the disease occurs before 6 days or for any period after 6 or 8 weeks. 
Neither is it known whether inoculation with immune gamma globulin allows 
hepatitis virus multiplication in the inoculated individuals. It has been sug- 
gested by workers in this field that individuals inoculated with immune gamma 
globulin and subsequently heavily exposed to hepatitis virus over several 
months' time may develop a more permanent type of immunity. One possible 
explanation of this is that active immunization may be superimposed on pas- 
sive protection under certain circumstances. These mechanisms might 
account for the lack of cases in the inoculated individuals for a period con- 
siderably beyond 6 or 8 weeks after inoculation. If one postulates that 
immune gamma globulin does allow virus infection and multiplication in the 
inoculated individual, but prevents clinical manifestations, then one would 
think that the disease rate among the uninoculated might actually increase 
after the time ©f initial mass inoculation because some individuals excreting 
virus, who would be removed from circulation by hospitalization if they had 
manifest disease, are in fact not removed because their infection is not recog- 
nizable. Admittedly, this manner of increasing the number of sources of 
infection might be a small factor if one considers the large number of natural 
epidemic and endemic subclinical cases available for spread of the disease. 

It would appear that one or all of the following factors may have been 
active to account for the sparsity of cases in the uninoculated group after the 
time of the initial mass inoculation and the complete absence of cases in this 
group for at least 3 months beginning 5 weeks after the mass inoculation: 



40 



Medical Newis Letter, Vol. 27, No. 11 



The individuals making up the uninoculated group were sufficiently separated 
from the higher disease incidence components and there was never a large 
number of infected individuals available to transmit the disease in these 
uninoculated components; An increased practice of good sanitary precautions 
on the part of all base personnel acted materially to diminish transmission 
of the hepatitis virus; The number of immune individuals (including the pas- 
sive immunes) was sufficient to materially curtail the spread on the base — 
a factor which would presume the concept that the immune individuals do not 
become virus excreters when infected. It would appear unlikely that no sus- 
ceptibles remained among the uninoculated group or that no sources for 
hepatitis virus existed at the base. 



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